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|
Attributes | |
ACN | 758668 |
Time | |
Date | 200710 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : hec.vortac |
State Reference | CA |
Altitude | msl single value : 33000 |
Environment | |
Flight Conditions | VMC VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla.artcc |
Operator | general aviation : corporate |
Make Model Name | Learjet 60 |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : intermediate altitude |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zla.artcc |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Experience | controller radar : 22 |
ASRS Report | 758668 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : private pilot : multi engine pilot : commercial pilot : instrument pilot : cfi pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 4500 flight time type : 500 |
ASRS Report | 758378 |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance |
Independent Detector | atc equipment : conflict alert aircraft equipment : tcas other controllera other flight crewa |
Resolutory Action | controller : issued new clearance controller : issued alert |
Miss Distance | horizontal : 36000 |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance |
Primary Problem | ATC Human Performance |
Narrative:
I had received a briefing to take the sector from the previous r-side controller. He descended aircraft X; an LJ60; to FL340. The pilot correctly responded to this clearance. I then took over the sector and had aircraft Y; a B752 climbing to FL310. When aircraft Y crossed the sector 38 boundary I climbed him to FL330 and the pilot responded correctly. I then descended aircraft Z from FL310 to FL240; calling the aircraft 'aircraft Z;' and I heard the pilot respond correctly. When aircraft X and aircraft Y were 20 mi apart I called the traffic to aircraft X as a B757 climbing to FL330 and told him to expect lower when clear. The pilot said he was looking. I was about to call the traffic to aircraft Y when I noticed aircraft X's mode C indicate FL335. I asked aircraft X to confirm level at FL340; but I felt that these 2 aircraft could collide and without waiting for a response I instructed aircraft X to turn 90 degrees right immediately and acknowledge with an identify. In the same breath I instructed aircraft Y to turn 90 degrees right immediately. When I un-keyed I got a blocked response and repeated the clearance to aircraft Y and the pilot responded. When the aircraft were laterally separated I turned aircraft Y to a 060 degree heading for additional traffic and later cleared him to inw. I cleared aircraft X direct hec. I felt this was a pilot deviation on aircraft X's part. The pilot was instructed to call in to ZLA on the next frequency. It took about 20 mins to relieve me from the sector and after I was relieved I took a walk around the facility parking lot to work out some of the adrenaline that was in my system. When I returned I was told by the operations manager that they had confirmed that aircraft X was assigned and acknowledged for FL340 and that they were filing a pilot deviation against the pilot. I would need to write a statement and the OM set up the falcon system for replay with audio. The OM asked if I would like a union rep and I said affirmative and while waiting for the rep I played the falcon display. I thought I heard some noise after aircraft Z responded to my FL240 clearance and I replayed it again and turned up the volume. You can hear aircraft Z responding to the clearance and if you listen carefully there is an 'air carrier X 240.' this was obviously aircraft X responding to aircraft Z's clearance. I asked the OM to listen and he confirmed what I heard although he was surprised since both he and my supervisor listened to the falcon and neither one heard aircraft X responding. Subsequently other mgrs have listened to audio and they also missed this readback. The OM asked me not to take this personally; but since I had missed the readback if a loss of separation had occurred I would be responsible. The pilot deviation was then canceled and the pilot was informed. The OM said he had a long discussion with the pilot about the bad readback since aircraft Z and aircraft X sound nothing alike. I informed the OM that I am not certain that aircraft X's bad readback ever made it through the electronics to my headset. I never let noise; heterodyne; or generally poor quality readbacks go by without questioning the pilots. As a general observation pilots are becoming very laid back lately with their radios. I am constantly needing to repeat myself and correct readbacks. They are very bad with not using their call signs and with making up their own poor phraseology. There needs to be some emphasis placed on good radio communications with the pilot through their operator/owners and with the FAA in general. If aircraft X had been paying attention this near midair collision would never have occurred. Supplemental information from acn 758378: I was PF of aircraft X. We were descending from FL400 and given intermediary dscnts. To the best of my recollection; the last clearance ATC gave us was to descend to FL240. I heard the PNF confirm FL240 with ATC. FL240 was rolled into our altitude selector to which I reiterated; 240; altitude select. We were roughly at FL360 at that point. I set up the VNAV in anticipation of descending to the next 12000 ft restr and noticed it would take a 2000 FPM descent to comply. At about 33700 ft; ATC informed us that our traffic would stop at FL330 and that we could expect lower after passing traffic. At that moment we realized something was wrong. We were closing the distance between our traffic and descending to their altitude. We disengaged the autoplt and started a right turn. Just then; ATC commanded a right 90 degree turn. Traffic was given the same instruction. We got a TA alert in the turn and continued our descent to increase separation. After we were clear of the conflict; the controller gave us a clearance to climb back to FL340 and shortly after a descent to FL280 direct hec. We were given a number to contact ZLA upon landing. We were told that the ZLA investigation found that we replied to another clearance to FL240 and they did not catch the mistake. They advised no action would be taken.
Original NASA ASRS Text
Title: ZLA CTLR DESCRIBED NEAR LOSS OF SEPARATION WHEN FLT CREW RESPONDED TO WRONG ALT CLRNC; CTLR FAILED TO HEAR INCORRECT READBACK.
Narrative: I HAD RECEIVED A BRIEFING TO TAKE THE SECTOR FROM THE PREVIOUS R-SIDE CTLR. HE DSNDED ACFT X; AN LJ60; TO FL340. THE PLT CORRECTLY RESPONDED TO THIS CLRNC. I THEN TOOK OVER THE SECTOR AND HAD ACFT Y; A B752 CLBING TO FL310. WHEN ACFT Y CROSSED THE SECTOR 38 BOUNDARY I CLBED HIM TO FL330 AND THE PLT RESPONDED CORRECTLY. I THEN DSNDED ACFT Z FROM FL310 TO FL240; CALLING THE ACFT 'ACFT Z;' AND I HEARD THE PLT RESPOND CORRECTLY. WHEN ACFT X AND ACFT Y WERE 20 MI APART I CALLED THE TFC TO ACFT X AS A B757 CLBING TO FL330 AND TOLD HIM TO EXPECT LOWER WHEN CLR. THE PLT SAID HE WAS LOOKING. I WAS ABOUT TO CALL THE TFC TO ACFT Y WHEN I NOTICED ACFT X'S MODE C INDICATE FL335. I ASKED ACFT X TO CONFIRM LEVEL AT FL340; BUT I FELT THAT THESE 2 ACFT COULD COLLIDE AND WITHOUT WAITING FOR A RESPONSE I INSTRUCTED ACFT X TO TURN 90 DEGS R IMMEDIATELY AND ACKNOWLEDGE WITH AN IDENT. IN THE SAME BREATH I INSTRUCTED ACFT Y TO TURN 90 DEGS R IMMEDIATELY. WHEN I UN-KEYED I GOT A BLOCKED RESPONSE AND REPEATED THE CLRNC TO ACFT Y AND THE PLT RESPONDED. WHEN THE ACFT WERE LATERALLY SEPARATED I TURNED ACFT Y TO A 060 DEG HDG FOR ADDITIONAL TFC AND LATER CLRED HIM TO INW. I CLRED ACFT X DIRECT HEC. I FELT THIS WAS A PLTDEV ON ACFT X'S PART. THE PLT WAS INSTRUCTED TO CALL IN TO ZLA ON THE NEXT FREQ. IT TOOK ABOUT 20 MINS TO RELIEVE ME FROM THE SECTOR AND AFTER I WAS RELIEVED I TOOK A WALK AROUND THE FACILITY PARKING LOT TO WORK OUT SOME OF THE ADRENALINE THAT WAS IN MY SYS. WHEN I RETURNED I WAS TOLD BY THE OPS MGR THAT THEY HAD CONFIRMED THAT ACFT X WAS ASSIGNED AND ACKNOWLEDGED FOR FL340 AND THAT THEY WERE FILING A PLTDEV AGAINST THE PLT. I WOULD NEED TO WRITE A STATEMENT AND THE OM SET UP THE FALCON SYS FOR REPLAY WITH AUDIO. THE OM ASKED IF I WOULD LIKE A UNION REP AND I SAID AFFIRMATIVE AND WHILE WAITING FOR THE REP I PLAYED THE FALCON DISPLAY. I THOUGHT I HEARD SOME NOISE AFTER ACFT Z RESPONDED TO MY FL240 CLRNC AND I REPLAYED IT AGAIN AND TURNED UP THE VOLUME. YOU CAN HEAR ACFT Z RESPONDING TO THE CLRNC AND IF YOU LISTEN CAREFULLY THERE IS AN 'ACR X 240.' THIS WAS OBVIOUSLY ACFT X RESPONDING TO ACFT Z'S CLRNC. I ASKED THE OM TO LISTEN AND HE CONFIRMED WHAT I HEARD ALTHOUGH HE WAS SURPRISED SINCE BOTH HE AND MY SUPVR LISTENED TO THE FALCON AND NEITHER ONE HEARD ACFT X RESPONDING. SUBSEQUENTLY OTHER MGRS HAVE LISTENED TO AUDIO AND THEY ALSO MISSED THIS READBACK. THE OM ASKED ME NOT TO TAKE THIS PERSONALLY; BUT SINCE I HAD MISSED THE READBACK IF A LOSS OF SEPARATION HAD OCCURRED I WOULD BE RESPONSIBLE. THE PLTDEV WAS THEN CANCELED AND THE PLT WAS INFORMED. THE OM SAID HE HAD A LONG DISCUSSION WITH THE PLT ABOUT THE BAD READBACK SINCE ACFT Z AND ACFT X SOUND NOTHING ALIKE. I INFORMED THE OM THAT I AM NOT CERTAIN THAT ACFT X'S BAD READBACK EVER MADE IT THROUGH THE ELECTRONICS TO MY HEADSET. I NEVER LET NOISE; HETERODYNE; OR GENERALLY POOR QUALITY READBACKS GO BY WITHOUT QUESTIONING THE PLTS. AS A GENERAL OBSERVATION PLTS ARE BECOMING VERY LAID BACK LATELY WITH THEIR RADIOS. I AM CONSTANTLY NEEDING TO REPEAT MYSELF AND CORRECT READBACKS. THEY ARE VERY BAD WITH NOT USING THEIR CALL SIGNS AND WITH MAKING UP THEIR OWN POOR PHRASEOLOGY. THERE NEEDS TO BE SOME EMPHASIS PLACED ON GOOD RADIO COMS WITH THE PLT THROUGH THEIR OPERATOR/OWNERS AND WITH THE FAA IN GENERAL. IF ACFT X HAD BEEN PAYING ATTN THIS NMAC WOULD NEVER HAVE OCCURRED. SUPPLEMENTAL INFO FROM ACN 758378: I WAS PF OF ACFT X. WE WERE DSNDING FROM FL400 AND GIVEN INTERMEDIARY DSCNTS. TO THE BEST OF MY RECOLLECTION; THE LAST CLRNC ATC GAVE US WAS TO DSND TO FL240. I HEARD THE PNF CONFIRM FL240 WITH ATC. FL240 WAS ROLLED INTO OUR ALT SELECTOR TO WHICH I REITERATED; 240; ALT SELECT. WE WERE ROUGHLY AT FL360 AT THAT POINT. I SET UP THE VNAV IN ANTICIPATION OF DSNDING TO THE NEXT 12000 FT RESTR AND NOTICED IT WOULD TAKE A 2000 FPM DSCNT TO COMPLY. AT ABOUT 33700 FT; ATC INFORMED US THAT OUR TFC WOULD STOP AT FL330 AND THAT WE COULD EXPECT LOWER AFTER PASSING TFC. AT THAT MOMENT WE REALIZED SOMETHING WAS WRONG. WE WERE CLOSING THE DISTANCE BTWN OUR TFC AND DSNDING TO THEIR ALT. WE DISENGAGED THE AUTOPLT AND STARTED A R TURN. JUST THEN; ATC COMMANDED A R 90 DEG TURN. TFC WAS GIVEN THE SAME INSTRUCTION. WE GOT A TA ALERT IN THE TURN AND CONTINUED OUR DSCNT TO INCREASE SEPARATION. AFTER WE WERE CLR OF THE CONFLICT; THE CTLR GAVE US A CLRNC TO CLB BACK TO FL340 AND SHORTLY AFTER A DSCNT TO FL280 DIRECT HEC. WE WERE GIVEN A NUMBER TO CONTACT ZLA UPON LNDG. WE WERE TOLD THAT THE ZLA INVESTIGATION FOUND THAT WE REPLIED TO ANOTHER CLRNC TO FL240 AND THEY DID NOT CATCH THE MISTAKE. THEY ADVISED NO ACTION WOULD BE TAKEN.
Data retrieved from NASA's ASRS site as of January 2009 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.